Provider Demographics
NPI:1164472734
Name:HOUSEKNECHT, JENNIFER (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HOUSEKNECHT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-3106
Mailing Address - Country:US
Mailing Address - Phone:574-875-4499
Mailing Address - Fax:855-326-4293
Practice Address - Street 1:3701 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-3106
Practice Address - Country:US
Practice Address - Phone:574-875-4499
Practice Address - Fax:855-326-4293
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002819152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU 65343Medicare UPIN